Intensive care units nosocomial pneumonia

Craig CP, Connelly S. Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality. Am J Infect Control 1984 12 233-238. 

In intensive care units (ICUs), pneumonia is the most frequent nosocomial infection (1-3) and occurs most often as ventilator-associated pneumonia (VAP) in patients on mechanical ventilation. The overall incidence of VAP in different studies varies between 10% and 85%, depending on the patient population and the criteria used to establish the diagnosis. Ventilator-associated pneumonia has been associated with an attributable mortality rate ranging from 13% to 47% (4-7), although this is not a consistent finding (8-10). 

Tod, M., Minozzi, C., Beaucaire, G., Ponsonnet, D., Gougnard, J., and Petitjean, O., Isepamicin in intensive care unit patients with nosocomial pneumonia population pharmacokinetic-pharmacodynamic study, /. Antimicrob. Chemother., 44, 99-108,1999. 

Prophylaxis of stress ulceration in intensive care units is the major interest to the anaesthetist. Here, it is given in a dose of 1 g every 6 hours via nasogastric tube. Several studies have shown sucralfate to be comparable in efficacy to H2 blockers. It has been claimed, but not proved, to result in a reduction in morbidity and mortality from nosocomial pneumonias in comparison to H2 antagonists. The latter, by raising gastric pH, eliminate the acid barrier to colonisation of the gut by pathogens, which sucralfate does not do. 

Selective decontamination of the gastrointestinal tract was conceptualised with a view to preventing nosocomial infection (mainly due to enterobacteriaciae), specifically ventilator-associated pneumonia, in intensive care units. Protocols typically included the prescription of an intravenous cephalosporin with good activity against such Gram-negative pathogens (e.g. cefotaxime) with co-prescribed, poorly... 

Chevret S., HemmerM., Carlet J., and LangerM. (1993) Incidence and risk factors of pneumonia acquired in intensive care units. Results from a multicenter prospective study on 996 patients. European Cooperative Group on Nosocomial Pneumonia. Intern. Care Med. 19, 256-264. 

Mcmullin, B.B., Chittock, D.R., Roscoe, D.L., Garcha, H., Wang, L., Miller, C.C., 2005. The antimicrobial effect of nitric oxide on the bacteria that cause nosocomial pneumonia in mechanically ventilated patients in the intensive care unit Respiratory Care 50,1451-1456. 

Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 1997 156 1647-1655. 

Fagon JY, Chastre J, Vuagnat A, et al. Nosocomial pneumonia and mortality among patients in intensive care units. JAMA 1996 275 866-869. 

Salata RA, Lederman MM, Shlaes DM, et al. Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients. Am Rev Respir Dis 1987 135 426-432. 

Nosocomial pneumonia is the second most common nosocomial infection (1) and the most common nosocomial infection in intensive care units (ICUs). It affects more than 250,000 acute care patients annually in the United States (2). The Centers for Disease Control and Prevention (CDC) recently estimated that nosocomial pneumonia is a primary or contributing cause for more than 30,000 deaths annually in the United States (3). To decrease the incidence of nosocomial pneumonia, hospitals must focus their considerable prevention efforts. However, these efforts begin by appropriate monitoring of this costly complication of hospital care. This task is even more involved because nosocomial pneumonia is probably more than one syndrome with multiple pathogeneses. 

Compared to most hospitalized patients, rates of nosocomial pneumonia are 10- to 20-fold higher in intensive care unit patients, and 7- to 21-fold higher in the intubated patients (4-6). Therefore, intubated patients in intensive care should be a major focus of surveillance for nosocomial pneumonia. Unit-... 

Mechanieally ventilated patients are exposed to multiple devices and are at particular risk of development of ventilator-associated pneumonia (VAP), the risk of which is proportional to the duration of assisted ventilation (see Table 4). The rates of nosocomial infections may be influenced by the type of intensive care unit in which the patient undergoes treatment, with higher rates observed in surgical intensive care than in medical ICU patients (22,129,130). We examine specific devices that have been associated with NP... 

Joshi N, Localio AR, Hamory BH. A predictive risk index for nosocomial pneumonia in the intensive care unit. Am J Med 1992 93 135-142. 

Tryba M. Risk of acute stress bleeding and nosocomial pneumonia in ventilated intensive care unit patients sucralfate versus antacids. Am J Med 1987 83(suppl) 117-124. 

Once the diagnosis of nosocomial pneumonia has been established, several important factors must be considered before a rational empirical antimicrobial regimen can be chosen. These include severity of illness and comorbid conditions of the patient, prior antibiotic use, early versus late onset of infection, results of the sputum Gram s stain, and the resident flora profile of the institution, particularly in the intensive care unit (Table 1). Empirical antimicrobial therapy for nosocomial pneumonia in a ventilated patient with renal failure in whom multiple intra-abdominal abscesses develop following colon resection is very different from the patient who aspirates following an otherwise uncomplicated cholecystectomy. 

Heyland D, Mandell LA. Gastric colonization by gram-negative bacilli and nosocomial pneumonia in the intensive care unit patient evidence for causation. Chest 1992 101 187-193. 

Chastre J, Fagon JY, Trouillet JL. Diagnosis and treatment of nosocomial pneumonia in patients in intensive care units. Clin Infect Dis 1995 2LS226-S237. 

Nosocomial lower respiratory tract infections may occur in children hospitalized in any area of a hospital. However, the children at greatest risk for nosocomial pneumonia and tracheitis are those cared for in an intensive care setting these account for >50% of all nosocomial pneumonias (28). Nosocomial lower respiratory tract infection will develop in approximately 2% to 10% of children in a pediatric intensive care unit. Similar but slightly lower proportions apply in infants cared for in neonatal intensive care units. 

A recent study performed in a Canadian pediatric intensive care unit identified specific risk factors or markers associated with bacterial nosocomial pneumonia and bacterial nosocomial tracheitis (38). By multivariate analysis, the following risk factors or markers (with odds ratio) were significantly associated with nosocomial infection ... 

Intubation associated with mechanical ventilation is the single most important risk factor for the development of nosocomial pneumonia and tracheitis. Intubation should be used only when medically indicated. Extubation should be accomplished as quickly as it is clinically feasible. It may be appropriate for individual pediatric and neonatal intensive care units to develop criteria for intubation and continued mechanical ventilation. Auditing practice versus predetermined criteria might identify opportunities to reduce patient ventilator-days. 

John M, Tucci M, Lacroix J, Farrell CA, Gauthier M, Lafleur L, Nadeau D. Nosocomial pneumonia and tracheitis in a pediatric intensive care unit. Am J Respir Crit Care Med 1997 155 162-169. 

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